Hybrid spreading mechanisms and T cell activation shape the dynamics of HIV-1 infection

HIV-1 can disseminate between susceptible cells by two mechanisms: cell-free infection following fluid-phase diffusion of virions and by highly-efficient direct cell-to-cell transmission at immune cell contacts. The contribution of this hybrid spreading mechanism, which is also a characteristic of some important computer worm outbreaks, to HIV-1 progression in vivo remains unknown. Here we present a new mathematical model that explicitly incorporates the ability of HIV-1 to use hybrid spreading mechanisms and evaluate the consequences for HIV-1 pathogenenesis. The model captures the major phases of the HIV-1 infection course of a cohort of treatment naive patients and also accurately predicts the results of the Short Pulse Anti-Retroviral Therapy at Seroconversion (SPARTAC) trial. Using this model we find that hybrid spreading is critical to seed and establish infection, and that cell-to-cell spread and increased CD4+ T cell activation are important for HIV-1 progression. Notably, the model predicts that cell-to-cell spread becomes increasingly effective as infection progresses and thus may present a considerable treatment barrier. Deriving predictions of various treatments' influence on HIV-1 progression highlights the importance of earlier intervention and suggests that treatments effectively targeting cell-to-cell HIV-1 spread can delay progression to AIDS. This study suggests that hybrid spreading is a fundamental feature of HIV infection, and provides the mathematical framework incorporating this feature with which to evaluate future therapeutic strategies

The utility of efavirenz-based prophylaxis against HIV infection. A systems pharmacological analysis

Pre-exposure prophylaxis (PrEP) is considered one of the five “pillars” by UNAIDS to reduce HIV transmission. Moreover, it is a tool for female self-protection against HIV, making it highly relevant to sub-Saharan regions, where women have the highest infection burden. To date, Truvada is the only medication for PrEP. However, the cost of Truvada limits its uptake in resource-constrained countries. Similarly, several currently investigated, patent-protected compounds may be unaffordable in these regions. We set out to explore the potential of the patent-expired antiviral efavirenz (EFV) as a cost-efficient PrEP alternative. A population pharmacokinetic model utilizing data from the ENCORE1 study was developed. The model was refined for metabolic autoinduction. We then explored EFV cellular uptake mechanisms, finding that it is largely determined by plasma protein binding. Next, we predicted the prophylactic efficacy of various EFV dosing schemes after exposure to HIV using a stochastic simulation framework. We predicted that plasma concentrations of 11, 36, 1287 and 1486ng/mL prevent 90% sexual transmissions with wild type and Y181C, K103N and G190S mutants, respectively. Trough concentrations achieved after 600 mg once daily dosing (median: 2017 ng/mL, 95% CI:445–9830) and after reduced dose (400 mg) efavirenz (median: 1349ng/mL, 95% CI: 297–6553) provided complete protection against wild-type virus and the Y181C mutant, and median trough concentrations provided about 90% protection against the K103N and G190S mutants. As reduced dose EFV has a lower toxicity profile, we predicted the reduction in HIV infection when 400 mg EFV-PrEP was poorly adhered to, when it was taken “on demand” and as post-exposure prophylaxis (PEP). Once daily EFV-PrEP provided 99% protection against wild-type virus, if ≥50% of doses were taken. PrEP “on demand” provided complete protection against wild-type virus and prevented ≥81% infections in the mutants. PEP could prevent >98% infection with susceptible virus when initiated within 24 h after virus exposure and continued for at least 9 days. We predict that 400 mg oral EFV may provide superior protection against wild-type HIV. However, further studies are warranted to evaluate EFV as a cost-efficient alternative to Truvada. Predicted prophylactic concentrations may guide release kinetics of EFV long-acting formulations for clinical trial design

The art of HIV elimination: past and present science

Introduction: Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges. Discussion: In the early days of the epidemic, behavioural approaches to control the HIV dominated, and the few available evidence-based interventions demonstrated to reduce HIV transmission were applied independently from one another. More recently, it has become clear that combination prevention strategies targeted to high transmission geographies and people at most risk of infections are required to achieve epidemic control. Biomedical strategies such as male medical circumcision and antiretroviral therapy for treatment in HIV-positive individuals and as preexposure prophylaxis in HIV-negative individuals provide immense promise for the future of HIV control. In resourcerich settings, the threat of HIV treatment optimism resulting in increased sexual risk taking has been observed and there are concerns that as ART roll-out matures in resource-poor settings and the benefits of ART become clearly visible, behavioural disinhibition may also become a challenge in those settings. Unfortunately, an efficacious vaccine, a strategy which could potentially halt the HIV epidemic, remains elusive. Conclusion: Combination HIV prevention offers a logical approach to HIV control, although what and how the available options should be combined is contextual. Therefore, knowledge of the local or national drivers of HIV infection is paramount. Problems with the HIV care continuum remain of concern, hindering progress towards the UNAIDS target of 90-90-90 by 2020. Research is needed on combination interventions that address all the steps of the cascade as the steps are not independent of each other. Until these issues are addressed, HIV elimination may remain an unattainable goal

A stochastic multi-scale model of HIV-1 transmission for decision-making: application to a MSM population.

BackgroundIn the absence of an effective vaccine against HIV-1, the scientific community is presented with the challenge of developing alternative methods to curb its spread. Due to the complexity of the disease, however, our ability to predict the impact of various prevention and treatment strategies is limited. While ART has been widely accepted as the gold standard of modern care, its timing is debated.ObjectivesTo evaluate the impact of medical interventions at the level of individuals on the spread of infection across the whole population. Specifically, we investigate the impact of ART initiation timing on HIV-1 spread in an MSM (Men who have Sex with Men) population.Design and methodsA stochastic multi-scale model of HIV-1 transmission that integrates within a single framework the in-host cellular dynamics and their outcomes, patient health states, and sexual contact networks. The model captures disease state and progression within individuals, and allows for simulation of therapeutic strategies.ResultsEarly ART initiation may substantially affect disease spread through a population.ConclusionsOur model provides a multi-scale, systems-based approach to evaluate the broader implications of therapeutic strategies

Systems medicine and infection

By using a systems based approach, mathematical and computational techniques can be used to develop models that describe the important mechanisms involved in infectious diseases. An iterative approach to model development allows new discoveries to continually improve the model, and ultimately increase the accuracy of predictions. SIR models are used to describe epi demics, predicting the extent and spread of disease. Genome-wide genotyping and sequencing technologies can be used to identify the biological mechanisms behind diseases. These tools help to build strategies for disease prevention and treatment, an example being the recent outbreak of Ebola in West Africa where these techniques were deployed. HIV is a complex disease where much is still to be learnt about the virus and the best effective treatment. With basic mathematical modelling techniques, significant discoveries have been made over the last 20 years. With recent technological advances, the computation al resources now available and interdisciplinary cooperation, further breakthroughs are inevitable. In TB, modelling has traditionally been empirical in nature, with clinical data providing the fuel for this top-down approach. Recently, projects have begun to use data derived from laboratory experiments and clinical trials to create mathematical models that describe the mechanisms responsible for the disease. A systems medicine approach to infection modelling helps identify important biological questions that then direct future experiments , the results of which improve the model in an iterative cycle . This means that data from several model systems can be integrated and synthesised to explore complex biological systems .Postprin

Probing entry inhibitors' activity on HIV and development of new fusion inhibitors : integrating evolutionary biology with virology

Tese de doutoramento, Farmácia (Microbiologia), Universidade de Lisboa, Faculdade de Farmácia, 2011The general aims of this thesis were: 1) to examine the C2, V3 and C3 envelope regions ofHIV-1 and HIV-2 at the molecular, evolutionary and structural levels; 2) to compare HIV-1and HIV-2 susceptibility to entry inhibitors and assess their potential value in HIV-2therapy; 3) to produce a new fusion inhibitor peptide using evolutionary biology basedstrategies.In the first study (Chapter 2), HIV-1 and HIV-2 were compared at the molecular,evolutionary and structural levels in the C2, V3 and C3 envelope regions. We identifiedsignificant structural and functional constrains to the diversification and evolution of C2,V3 and C3 in the HIV-2 envelope but not in HIV-1. In particular, we found that V3 in HIV-2is less exposed and more conserved than in HIV-1, suggesting fundamental differences inthe biology and infection of these viruses as well as in their susceptibility to entryinhibitors.In the second study (Chapter 3) we measured the baseline susceptibility of HIV-1 and HIV-2primary isolates to different fusion inhibitors and coreceptor antagonists, includingenfuvirtide (T-20) and maraviroc (MVC). MVC inhibited HIV-2 R5 variants at significantlyhigher IC90 concentrations than HIV-1 variants. Moreover, as previously found in HIV-1,susceptibility of HIV-2 R5 variants to MVC was inversely related with CD4+ T cell counts attime of virus isolation. These results suggest that the structure of the envelope complex ofR5 variants changes along the course of infection. More importantly, the results call fornew clinical studies to evaluate the efficacy of MVC in HIV-2 infection and to determine itsbest therapeutic dosage in early and late stage disease. We also provide definitiveevidence demonstrating that T-20 is not useful for HIV-2 therapy.In the final study (Chapter 4), we designed a new HIV fusion inhibitor peptide (P3) basedon the ancestral sequences of the HIV-2 and SIV envelope genes. P3 has an a-helixstructure as demonstrated by circular dichroism. It has broad antiviral activity at thenanomolar range against HIV-1 and HIV-2 primary isolates, including HIV-1 variantsresistant to T-20. Binding ELISA assays and selection of resistant mutants suggest that P3prevents viral fusion by binding to the transmembrane protein in the HR1 region. Thesestudies provide proof of concept that viable antiviral peptides can be constructed usingevolutionary biology strategies. Such strategies should be explored to enhance theproduction of peptide drugs and vaccines.O Vírus da Imunodeficiência Humana do tipo 1 e do tipo 2 (VIH-1 e VIH-2) são os agentes etiológicos do Síndrome de Imunodeficiência Adquirida (SIDA). Embora sejam semelhantes na sua organização estrutural e genómica, estes lentivírus humanos apresentam características antigénicas distintas e partilham uma semelhança genética de apenas 50%. Enquanto o VIH-1 é responsável pela pandemia mundial, a infecção pelo VIH-2 localiza-se sobretudo na África Ocidental, em alguns países europeus como Portugal e França, e na Índia. A infecção pelo VIH-2 tem melhor prognóstico, a progressão para a doença é mais lenta e há melhor controlo imunológico do que na infecção pelo VIH-1. Ao contrário do VIH-1, o arsenal terapêutico actualmente disponível para tratar a infecção por VIH-2 é reduzido. Os fármacos antiretrovirais em uso foram especificamente desenvolvidos para o VIH-1 e, consequentemente, a sua actividade pode ser reduzida ou nula no VIH-2. Este é o caso concreto dos inibidores não nucleosídicos da transcriptase reversa e de alguns inibidores da protease. Neste contexto, os inibidores de entrada poderão ser úteis para tratar a infecção por VIH-2. Contudo, a susceptibilidade dos isolados primários de VIH-2 aos inibidores de entrada é actualmente desconhecida. A susceptibilidade do VIH aos inibidores de entrada é determinada pela qualidade da interacção do vírus com os receptores celulares. O VIH-1 e VIH-2 são substancialmente diferentes a este nível. Por exemplo, o VIH-2 pode ligar-se ao co-receptor CCR5 independentemente do receptor CD4 e da região V3 do invólucro. Por outro lado, as regiões C2, V3 e C3 do VIH-2 são substancialmente diferentes do VIH-1 a nível antigénico. Colectivamente, estes dados indicam que a estrutura e conformação das glicoproteínas de superfície do VIH-1 e VIH-2 são substancialmente diferentes e sugerem que a susceptibilidade e resistência dos dois tipos de vírus aos inibidores de entrada podem também ser diferentes. Os principais objectivos desta tese foram: 1) analisar as características moleculares, estruturais e evolutivas das regiões C2, V3 e C3 no VIH-1 e VIH-2; 2) comparar a susceptibilidade do VIH-1 e VIH-2 aos inibidores de entrada e avaliar o seu potencial terapêutico na infecção por VIH-2; 3) produzir um novo inibidor de fusão para o VIH-2. Para melhor compreender as potenciais diferenças destes dois vírus na resposta aos inibidores de entrada começámos por analisar as características moleculares, estruturais e evolutivas da região V3 e as regiões circundantes C2 e C3, num número significativo de vírus VIH-1 e VIH-2 isolados em Portugal e noutras regiões do globo, com recurso a diferentes metodologias de biologia evolutiva e computacional (Capitulo 2). Apesar da menor variabilidade das 3 regiões no VIH-2, verificámos que a região C3 está sob forte selecção positiva e encontra-se exposta à superfície sugerindo que, tal como no VIH-1, esta região poderá constituir um domínio neutralizante. No entanto, ao contrário do VIH-1, a maioria das mutações adaptativas no VIH-2 são prejudiciais e levam à extinção das linhagens virais pelo que o efeito final é um forte constrangimento à variabilidade das regiões analisadas. Ao contrário do VIH-1, verificámos que a ansa V3 do VIH-2 se encontra oclusa no complexo glicoproteico do invólucro, numa conformação que parece ser estabilizada por interacções que mantém com alguns resíduos da regiões C2 e C3. Estes resultados são consistentes com o facto de a V3 não ser imunodominante no VIH-2, ficando assim mais protegida da resposta imunitária e das eventuais mutações que dela resultam. A forte conservação da V3, da C2 e da C3 também é consistente com a sua potencialmente importante actividade imunosupressora. Em conclusão, este primeiro estudo permitiu caracterizar algumas das características estruturais e funcionais que distinguem as glicoproteínas do invólucro do VIH-1 e do VIH-2 e que estão associadas às diferentes características biológicas e fenotípicas destes dois vírus. Estes dados podem ter impacto na resposta dos dois vírus aos inibidores de entrada (analisado no Capítulo 3) e no desenvolvimento de novas vacinas. No segundo estudo (Capítulo 3) comparámos a actividade antiviral dos antagonistas dos coreceptores (AMD3100, TAK-779 e maraviroc) e dos inibidores de fusão (T-20 e T-1249) entre um grupo de 20 isolados de VIH-2 (19 isolados primários + um isolado laboratorial) e nove isolados de VIH-1 (sete isolados primários + dois isolados laboratoriais). Verificámos que a sensibilidade ao AMD3100 e ao TAK-779 é semelhante no VIH-1 e o VIH-2. No entanto, o perfil da curva dose-resposta do maraviroc (MVC) obtido para os isolados R5 foi diferente nos dois tipos de vírus. No VIH-2 os valores de IC90 foram significativamente mais elevados do que no VIH-1; por outro lado, os declives da curva dose-resposta foram mais baixos no VIH-2 do que no VIH-1. Colectivamente, estes resultados sugerem que poderão ser necessárias concentrações mais elevadas de MVC para tratar os doentes infectados pelo VIH-2. Adicionalmente, encontrámos uma correlação forte e de sentido inverso entre as susceptibilidade do VIH-2 ao MVC e o número de células T CD4+ dos doentes quando os vírus foram isolados. Vírus isolados em doentes em fase de SIDA foram menos susceptíveis ao MVC do que os vírus isolados em doentes com uma contagem de células T CD4+ superior a 200 células/ul. Ao contrário do VIH-1 não encontrámos qualquer correlação entre a carga da V3 e a susceptibilidade dos isolados R5 de VIH-2 ao MVC. De um modo geral, os nossos resultados sugerem que são necessários ensaios clínicos para avaliar a efectividade do MVC na infecção pelo VIH-2, determinar a dose terapêutica mais adequada e esclarecer se é necessário fazer um ajuste de dose de acordo com a fase da doença. Adicionalmente, e uma vez que isolados VIH-2 X4 e populações duplas/mistas são totalmente ou parcialmente resistentes ao MVC, é de extrema importância o desenvolvimento de um ensaio de tropismo (genotípico e/ou fenotípico) para o VIH-2 de modo a determinar o tropismo antes do início da terapia com MVC. Sem o conhecimento prévio do tropismo viral, o tratamento com MVC poderá seleccionar espécies X4 minoritárias que estão associadas a maior resistência à neutralização e uma progressão mais rápida da doença. No que diz respeito aos inibidores de fusão, verificámos que o T-20 tem actividade reduzida no VIH-2, confirmando estudos anteriores realizados com dois isolados laboratoriais. Por outro lado, observámos uma elevada susceptibilidade deste vírus ao T- 1249, indicando que os inibidores de fusão são potencialmente eficazes na infecção pelo VIH-2. Assim, o desenvolvimento de um novo inibidor de fusão do VIH-2 foi o objectivo do último estudo desta tese (Capítulo 4). No Capítulo 4, desenvolvemos novos péptidos inibidores de fusão a partir da reconstrução de sequências ancestrais da glicoproteína gp36 do invólucro de VIH-2 e de Vírus de Imunodeficiência dos Símios (VIS). Com esta abordagem inovadora pretendemos incorporar a história evolutiva dos vírus na sequência dos péptidos e desta forma melhorar a tolerância destas moléculas aos polimorfismos naturais da sua região alvo bem como às mutações de resistência seleccionadas na sua presença. Obteve-se um péptido ancestral (P3) constituído por 34 aminoácidos, cuja sequência corresponde às posições homólogas 628 – 661 da proteína Env do isolado VIH-1 HXB2 (ou 623 – 656 do isolado VIH-2 ROD). A sequência do P3 difere em 21 aminoácidos da sequência consenso de VIH-1, 14 aminoácidos da sequência do T-20 e 6 aminoácidos da sequência consenso de VIH-2. Ao contrário da natureza não-estruturada do T-20, o P3 tem uma conformação típica em hélice-a, o que lhe poderá conferir maior a estabilidade contra a degradação proteolítica, bem como maior afinidade para a região alvo. Por outro lado, o P3 foi facilmente solúvel em soluções aquosas o que é uma vantagem num futuro desenvolvimento de uma fórmula farmacêutica. O P3 demonstrou ter uma forte actividade antiviral contra isolados primários e laboratoriais de VIH-1 e VIH-2 (IC50 médio, 11 nM para o HIV-1 e 63.8 nM para o HIV-2), incluindo variantes resistentes ao T-20 (IC50, 0.15 – 11.8 nM). Através da passagem consecutiva de vírus em cultura na presença do péptido, foi seleccionada uma mutação de resistência na região HR1 da gp41 (VIH-1), a qual é responsável pela redução da susceptibilidade do VIH-1 ao P3 em 120x. Nas mesmas condições, e após 60 dias em cultura, não foi possível seleccionar mutações de resistência ao P3 no VIH-2. Estes resultado, em conjugação com a sua forte ligação à glicoproteína transmembranar de um isolado de VIH-2, indicam que, tal como outros péptidos baseados na região HR2 (T-20, T- 1249), o P3 inibe a entrada do VIH pela interacção com a região HR1 da gp41 e sugerem que a barreira genética para a resistência ao P3 é significativamente superior no VIH-2 do que no VIH-1. Neste estudo demonstrámos ainda que o P3 é significativamente menos antigénico do que o T-20 nos doentes infectados pelo VIH-1 o que poderá traduzir-se numa maior duração da eficácia clínica do P3 em comparação com o T-20. Os resultados obtidos com o P3 demonstram pela primeira vez que é possível desenvolver péptidos com actividade antiviral significativa utilizando metodologias de biologia evolutiva, pelo que esta abordagem poderá ser explorada no futuro para a produção de medicamentos peptídicos e, eventualmente, de vacinas

Modelling Multiple Dosing with Drug Holiday in Antiretroviral Treatment on HIV-1 Infection

A within-host mathematical model to describe the dynamics of target cells and viral load in early HIV-1 infection was developed, which incorporates a combination of RTI and PI treatments by using a pharmacokinetics model. The local stability of uninfected steady state for the model was determined using an alternative threshold. The pharmacokinetics model was employed to estimate drug efficacy in multiple drug dosing. The effect of periodic drug efficacy of pharmacokinetic type on outcome of HIV-1 infection was explored under various treatment interruptions. The effectiveness of treatment interruption was determined according to the time period of the drug holidays. The results showed that long drug holidays lead to therapy failure. Under interruption of treatments combining RTI and PI therapy, effectiveness of the treatment requires a short duration of the drug holiday.

An integrated modelling approach for R5-X4 mutation and HAART therapy assessment

We have modelled the within-patient evolutionary process during HIV infection using different methodologies. New viral strains arise during the course of HIV infection. These multiple strains of the virus are able to use different coreceptors, in particular the CCR5 and the CXCR4 (R5 and X4 phenotypes, respectively)influence the progression of the disease to the AIDS phase. We present a model of HIV early infection and CTLs response which describes the dynamics of R5 quasispecies, specifying the R5 to X4 switch and effects of immune response. We illustrate dynamics of HIV multiple strains in the presence of multidrug HAART therapy. The HAART combined with X4 strain blocker drugs might help to reduce infectivity and lead to slower progression of disease. On the methodology side, our model represents a paradigm of integrating formal methods and mathematical models as a general framework to study HIV multiple strains during disease progression, and will inch towards providing help in selecting among vaccines and drug therapies. The results presented here are one of the rare cases of methodological cross comparison (stochastic and deterministic) and a novel implementation of model checking in therapy validation

The use of the SAEM algorithm in MONOLIX software for estimation of population pharmacokinetic-pharmacodynamic-viral dynamics parameters of maraviroc in asymptomatic HIV subjects

Using simulated viral load data for a given maraviroc monotherapy study design, the feasibility of different algorithms to perform parameter estimation for a pharmacokinetic-pharmacodynamic-viral dynamics (PKPD-VD) model was assessed. The assessed algorithms are the first-order conditional estimation method with interaction (FOCEI) implemented in NONMEM VI and the SAEM algorithm implemented in MONOLIX version 2.4. Simulated data were also used to test if an effect compartment and/or a lag time could be distinguished to describe an observed delay in onset of viral inhibition using SAEM. The preferred model was then used to describe the observed maraviroc monotherapy plasma concentration and viral load data using SAEM. In this last step, three modelling approaches were compared; (i) sequential PKPD-VD with fixed individual Empirical Bayesian Estimates (EBE) for PK, (ii) sequential PKPD-VD with fixed population PK parameters and including concentrations, and (iii) simultaneous PKPD-VD. Using FOCEI, many convergence problems (56%) were experienced with fitting the sequential PKPD-VD model to the simulated data. For the sequential modelling approach, SAEM (with default settings) took less time to generate population and individual estimates including diagnostics than with FOCEI without diagnostics. For the given maraviroc monotherapy sampling design, it was difficult to separate the viral dynamics system delay from a pharmacokinetic distributional delay or delay due to receptor binding and subsequent cellular signalling. The preferred model included a viral load lag time without inter-individual variability. Parameter estimates from the SAEM analysis of observed data were comparable among the three modelling approaches. For the sequential methods, computation time is approximately 25% less when fixing individual EBE of PK parameters with omission of the concentration data compared with fixed population PK parameters and retention of concentration data in the PD-VD estimation step. Computation times were similar for the sequential method with fixed population PK parameters and the simultaneous PKPD-VD modelling approach. The current analysis demonstrated that the SAEM algorithm in MONOLIX is useful for fitting complex mechanistic models requiring multiple differential equations. The SAEM algorithm allowed simultaneous estimation of PKPD and viral dynamics parameters, as well as investigation of different model sub-components during the model building process. This was not possible with the FOCEI method (NONMEM version VI or below). SAEM provides a more feasible alternative to FOCEI when facing lengthy computation times and convergence problems with complex models